The World Health Organization statedthat less than 1% of the population is affected by Rigid flatfoot which causespain and disability that may require surgery. While in the U.S. adultpopulation between 2 to 23% is affected by flexible flatfoot.

(Banwell et al., 2014)Symptomatic Flatfoot is considered pathological, the hindfoot medial region and the posterior tibial tendon iswhere the pain generally occurs, sometimes it may be associated with the tendonsheath effusion.(Toullec, 2015)Painful symptoms accompanyingflexible flatfoot include, a wide distribution of pain and an increase infatigue rate in lower limb area, osteoarthritis, achilles tendinopathy andpatellofemoral disorders may appear. Other signs observed include the abnormalappearance of rearfoot kinematics such as a rearfoot excessive eversion or byan increase in the eversion range, abnormal kinetics of the foot and ankle suchas joint moments elevated or loading forces abnormal values and change in thephysical function by abnormal timing and activation of muscles or by raising consumptionof energy. These functional consequences are the reason for the symptomaticflexible flatfoot, and the intervention should target these abnormalities.(Banwell et al., 2014)In adult acquired ?atfoot, the deformityis due to arthritic changes, neuromuscular diseases, and traumatic conditions.

While the most common deformity cause remains posterior tibial tendondysfunction, many conditions could cause the tendon dysfunction such as ruptureand secondary arthritis which is considered the most severe sequelae, in the U.S.about 5 million people are affected by this condition.(Abousayed et al., 2016) Adult acquired flatfoot can becaused by many conditions such as, ankle degeneration changes that happen inthe tarsometatarsal or talonavicular or both, these degenerations occursecondary to fractures, inflammatory arthropathy and Osteoarthropathy. the Neuropathicfoot that occur secondary to leprosy, diabetes mellitus and profound peripheralneuritis. Loss of support at the medial longitudinal arch seen in tibialisposterior tendon dysfunction or calcaneoanvicular ligament tear.

Otherconditions for painful flatfoot may include tarsal coalition. Risk factorsinclude middle-aged women, hypertension, diabetes mellitus, injecting the areaaround the tendon with steroid, and seronegative arthropathies. These factorsare observed in the tibialis posterior tendon insufficiency condition.(Kohls-Gatzoulis et al., 2004)In flexible flatfoot etiopathologythis study indicated, while the normal medial longitudinal arch of the foot isformed by the foot bones which are supported by ligaments, tendon and capsularstructures, the medial longitudinal arch is not preserved by the foot muscles.The electromyographic research resulted in that intrinsic and extrinsic musclesdidn’t help in reinforcing nor preserving the medial longitudinal arch whileassuming a standing position (Basmajian and Stecko, 1963). although during walking the dynamic stabilization of the arch ismaintained by muscles in the both groups, this statement is reinforced by astudy that resulted in that intrinsic muscles of the foot have an importantrole in supporting the medial longitudinal arch (Fiolkowski et al., 2003).

In the posterior tibial tendon insufficiency flatfoot, it hasbeen emphasized on the musculature importance, as shown in this study whichresulted that in anatomical structure the most significant structure was the plantarfascia due to its role in stabilizing the medial arch, along with the talonavicular,and spring ligaments.(Huang et al., 1993) In adult, flexible flatfoot mayappear bilateral or unilateral, the main symptoms are pain at arch, heel, andthe foot lateral aspect, these symptoms are aggravated by activities thatinclude weight bearing such as running, walking, and hiking. Orthotics isconsidered to be an early treatment option for this condition(Lee et al., 2005), its designed to stabilize and realign the foot arch, symptomsrelief is a noticeable success in patient.

(Chen et al., 2010)Ina search of the biomechanical effects of wearing foot orthotics on medial longitudinalarch in patient with flexible flatfoot from the literature, one study comparedbetween the effect of short foot exercises and the use of insoles on the medialarch, in the orthotic group the orthoticwas made to affect the medial arch height (value of 20Ā° and a height of atleast 15 mm) and was standard for all patient. The parameters assessedwas measuring the changes in the height of the medial longitudinal arch, whichresulted in that short foot exercises are more effective and insoleĀ 

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